Friday, May 23, 2014

I frequently receive requests for information from parents or therapists of very young children - usually between the ages of 18 and 30 months. The children have very few, if any, words. They make few sounds. They have a history of reduced or absent babbling. They have difficulty imitating and difficulty making volitional utterances. They are beginning to become aware that they are different. They want to communicate and yet struggle. Frustration is increasing on the part of both parents and children. The child may begin to act out in negative ways. What do you do? Where do you start?

You have three immediate goals:

Reduce frustration.

Establish and increase frequency of volitional utterances.

Increase number of daily speech utterances through structured practice.

Early Apraxia Treatment - Increase number of daily speech utterances through structured practice.

Childhood Apraxia of Speech is a disorder of the motor planning of speech movements. The brain knows what the child wants to say. The mouth is capable of making the movements necessary. The planning of those movements gets jumbled in between. Children with apraxia need repetition, repetition, repetition in order to establish proper motor planning routines and make those routines smooth and automatic. One of the most efficient ways to increase the sheer number of repetitions your child makes is through drill. You can do drill activities with very young children, but first you need to figure out what to drill. I will outline a sequence of steps that will show you how to determine which sounds to target first for a specific child and help you find the resources and methods for doing those drill activities with young children.

Take a speech sound inventory - Young children with apraxia often have a “limited phonemic repertoire”. This is just a fancy way of saying that they can’t make very many sounds. Even if they are trying to mimic a wide variety of words, the sounds they are actually producing often are not the sounds that should be in the words they are trying to imitate. Listen carefully to your child when they are verbalizing. Take videos of several times when your child is “chatty”. Then go back and really listen to those utterances. Transcribe them if you can. What sounds do you hear? What vowels? What consonants? Write those down. For example, check out this speech sample of a child with apraxia at 23 months of age. You can see the transcript of the words Ava was saying and the actual sounds she produced. You'll want to do this several times so that you can be sure that you have a fairly complete collection of the types of utterances your child can make.

Analyze the speech sound data you collected - Take your lists of the transcribed words your child makes (if you are a parent, you don't have to use fancy transcription symbols like I did -just note vowels and consonants as best you can). From those lists, make a final list of all the consonant sounds your child can produce. If you can, note next to each consonant whether you heard it at the beginning of the word (in initial position) or at the end of the word (in final position) or both. Your list of consonants may be very small. When I started working with Ava, her only consonant was /d/. You may hear several consonants. If so, try to identify the one or two consonants your child uses most often. Or, the one or two consonants they can imitate best.

Choose speech practice target sounds - This may seem counterintuitive, but you want to begin by working with the sounds your child is most successful with. You are going to begin practicing with the one or two sounds that they already use the most and/or that they can imitate the best. You are going to do this for two reasons. First, you want them to experience success. Early apraxia therapy is all about turning speech from a frustrating activity the child feels like a failure at to a fun activity they can enjoy and consistently participate in at some level. Second, it is likely that they are only using those "best" consonants in a single word, or that they cannot produce them at will in many situations. You want to take that sound that they are currently only using in one word, at home, with you and turn it into a sound they can use in many words (with different vowels to mean different things) in many different situations (school, with other family members, at the park, etc.).

Make therapy practice materials - Go to my free speech articulation materials page and download a free card set or two. Choose a card set that features the sounds you identified in the previous step. If your child uses the sound at the beginning of their words, download the initial card set for that sound. If your child uses the sound at the end of their words, download the final card set for that sound. The card set is designed to pair that consonant your child can produce successfully with multiple vowels. If they leave off a sound (for example, "pah" for "pop"), accept that as correct and move on. If there are cards in the set that your child cannot produce because they can't imitate that vowel sound at all, don’t use them. Right now you want your child to think that this game is fun. You want them to experience success.

Scroll down to the bottom of the free card set page for some tips on doing speech practice with young children and 30 ideas of games and activities to do with those cards.

Practice, practice, practice - Keep practice sessions short. Treat it as play. Tell your child that you're going to play a speech game and then follow through with making it fun. If your child is struggling, ask for just one more, and then put it aside and come back to it later, with a different game. Remember that all of these speech repetitions are cumulative. You are using a variety of strategies throughout the child's entire day to increase the number of speech utterances they produce. Structured practice with picture cards can easily double a the number of speech utterances a child produces in a day in a very short amount of time. It is a valuable tool. It also allows your child to practice using very simple combinations of sounds to produce a wide variety of words that they will hopefully begin to be able to incorporate into their own spontaneous use.

Thursday, May 22, 2014

I frequently receive requests for information from parents or therapists of very young children - usually between the ages of 18 and 30 months. The children have very few, if any, words. They make few sounds. They have a history of reduced or absent babbling. They have difficulty imitating and difficulty making volitional utterances. They are beginning to become aware that they are different. They want to communicate and yet struggle. Frustration is increasing on the part of both parents and children. The child may begin to act out in negative ways. What do you do? Where do you start?

You have three immediate goals:

Reduce frustration.

Establish and increase frequency of volitional utterances.

Increase number of daily speech utterances through structured practice.

Early Apraxia Treatment - Reducing frustration.

Typically, very young children with apraxia have difficulty producing sounds when they want to. You want to help them be able to intentionally vocalize. If they already can vocalize at will, you want to increase the number of those utterances and the contexts in which they can produce those utterances. Note that for the purpose of this goal, you should not care if the utterance is phonetically accurate. For example, if the child is trying to say, “baby”, and the utterance they make doesn’t sound anything like “baby,” that is all right. If they produce something different each time, that is all right too. You simply want them to be able to reliably produce an utterance in response to a stimulus.

Every time a child with apraxia makes a vocalization (any vocalization) on purpose they are practicing formulating a message in their mind, creating a motor-speech plan, and successfully coordinating breath, phonation, and movement of the speech articulators to produce sound. For these children, that sequence of events is a huge success and a necessary beginning. You need this to happen before you can begin to fine tune the specific sounds that emerge. There are many ways to establish and increase practice opportunities for volitional utterances. I will describe four methods below.

Echoing - One of the simplest ways to establish or increase the number of volitional utterances is to echo any utterances your child does make back at them. Remember that every single time your child deliberately makes a sound to communicate they are coordinating intent with breath, phonation, and movement of speech muscles and structures. This is essential practice in early apraxia therapy. So, if your child happens to make a sound (not a frustration sound, but any other sound) echo it back at them. You want to try to create a fun feedback loop or simple game out of bouncing that word/sound/exclamation/utterance back and forth. For example, there was a time when my daughter's only word was "da?" (for "that?"). She would use it to label items she already knew the name for, to request the name for unknown items, and to request items she couldn't reach. She and I could have an entire conversation consisting of bouncing that one word back and forth. She would point to an unknown item (let's say... a marble, just for the sake of this example). The conversation would unfold as follows:

Ava: "Da?" (What's that?)

Mama: "Da?" (You mean this?)

Ava: "Da!" (Yep!)

Mama: "Da?" (You sure you mean this?)

Ava: "Da!" (Yep mama. Tell me already!)

Mama: "Marble."

So, instead of her making a single utterance and then receiving either the marble or the label for the marble and being done, Ava practiced making an utterance three times in the context of a true, turn-taking conversation. Over time, this simple technique can result in dozens, or hundreds of extra utterances a day. You can listen to an example of a father using this technique with his 21 month old daughter in the first apraxia speech sample audio clip of this post.

Interactive book reading - Sit down with your child and a picture book. Your goal is to use the book interactively to elicit speech from your child. Read the same book each night so that the child sees the book as a familiar and fun activity. You do not want to read the book to your child, although you can make reading the text on each page part of what you do. You want to engage your child in commenting on the action in the pictures by pointing and asking questions. For example, if a story involves a character who falls, every time you read that page, point to the character and say, “Uh oh!” Then encourage your child to mimic you. Go back and forth several times. Have fun with it. Other utterances that can be worked into reading many children’s books include “hi,” “oh no,” “shhhh,” “bye bye,” “mama,” “daddy,” etc. Again, it doesn’t matter so much that your child mimics those words correctly. You simply want them to experience the turn taking and joint attention that comes with playing the game.

Pair actions and vocalizations - Often children with apraxia find vocalizing easier when their efforts are paired with motion. Encourage your child to say “whee” while sliding down a slide or swinging on a swing. Play horsie and bounce them on your knee or on an exercise ball while saying “ba bump, ba bump, ba bump”. Blow bubbles and encourage them to say “pop” as they pop each one with their finger. Crash cars together and have them mimic “bam!” Give them a ball of play dough and let them poke holes in it imitating “squish” each time. Line up blocks along the end of a table and have them say “uh oh” each time they push one off. Then they can say “up” each time they put one back up setting up for the next round. Possibilities are endless. Again, it doesn’t so much matter what sound they make. What matters is that they do make a sound. You want them to enjoy making the sound. Making a sound is part of the game. Without a sound, the game isn’t as much fun.

Strategic Withholding - Create speech opportunities in daily life. Structure interactions to require speech. It is so easy with a minimally verbal child to start anticipating their needs and eliminate the need for them to even try to vocalize. Instead, deliberately place a few favorite things out of reach so they have to ask for your help to reach them. Give them a small serving of their favorite food so they’ll need to ask for more. If you are coloring with them, deliberately place the colors just a little out of their reach so they’ll have to ask you to hand them the crayons. These are just a few simple examples, but extend the concept as much as possible during the day. Through this simple technique you can create dozens of opportunities for your child to verbalize each day. Every single utterance adds up to extra practice. A child with apraxia needs as much practice as you can possible squeeze in.

Do not take this to extremes. You are not trying to be mean, or to deliberately frustrate the child. You are simply intentionally creating opportunities for requests. You want the process to feel natural and not forced. If the child is not able to vocalize a request, respond to nonverbal requests (and signs) as well. You want to avoid increasing frustration. Think “create opportunities” rather than “force practice.”

Trying to write this as one continuous post was simply too long. Look for the continuation of this series the rest of the week. In the meantime, if you need more general information about Childhood Apraxia of Speech, the following posts may be useful:

Wednesday, May 21, 2014

I frequently receive requests for information from parents or therapists of very young children - usually between the ages of 18 and 30 months. The children have very few, if any, words. They make few sounds. They have a history of reduced or absent babbling. They have difficulty imitating and difficulty making volitional utterances. They are beginning to become aware that they are different. They want to communicate and yet struggle. Frustration is increasing on the part of both parents and children. The child may begin to act out in negative ways. What do you do? Where do you start?

You have three immediate goals:

Reduce frustration.

Establish and increase frequency of volitional utterances.

Increase number of daily speech utterances through structured practice.

Early Apraxia Treatment - Reducing frustration.

Both child and parents experience increasing frustration. The child has the cognition and underlying receptive and expressive language skills to want to communicate and yet the child is unable to talk. The child wants to initiate simple requests - they want attention, food, help, an item out of reach, etc. When they are unable to make those requests they are frustrated and act out in frustration. They also resort to grabbing, pulling, pointing, crying, and grunting as they attempt to communicate. You need to reduce all of this frustration to improve the quality of life for the child and everyone around him or her. The child needs to be able to communicate their basic needs. You need to teach temporary ways for the child to communicate effectively.

Teach simple signs - Teach the child simple signs such as "no, stop, more, help, eat, drink," etc. Teach the same signs to any adults and other children who regularly spend time with the child. Incorporate the use of these signs into daily routines and encourage the child to use them as well. Adults and other children should pair the use of the sign with the matching spoken word, but do not push the child with apraxia to vocalize. The purpose of using the signs at this point is to allow the child to communicate functionally when their voice fails them. This will result in a happier child who will be able to better understand the underlying give-and-take nature of communication when you are ready to bridge to verbal communication. Here's a visual guide to 21 signs useful with young children.

Create communication boards - Create communication boards and post them in key areas of the child's home. Make a simple chart of food and drink items to put on the wall in the kitchen (at a height the child can reach). Post another chart with characters from their favorite TV shows near the television. A third chart might include pictures of the toys they request most often posted near the place toys are put away. This gives the child a way to request specific things without needing to be able to verbalize complex sounds.

Think about the things the child most often struggles to communicate and create boards that feature those things. For more in depth information, read about why and how to make and use communication boards in my Apraxia Therapy: Communication Boards post.

Trying to write this as one continuous post was simply too long. Look for the continuation of this series the rest of the week. In the meantime, if you need more general information about Childhood Apraxia of Speech, the following posts may be useful:

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